Confidential draft / Policy under development / Statements are not binding on
MassHealth
Primary Care Payment Reform Open Meeting: Overview
Wednesday, October 10th
Confidential draft / Policy under development / Statements are not binding on
MassHealth
Agenda
• Recap of program
• Stakeholder engagement process
• Intersection with other programs
• Clarification of financial model
• Review of RFI feedback
2
Confidential draft / Policy under development / Statements are not binding on
MassHealth
What are we trying to accomplish?
• We want to improve access, patient experience, quality, and efficiency, and we
believe primary care is a key force in accomplishing that
• However, the current fee for service system does not optimally support primary
care providers (PCPs) in achieving those objectives
• PCPs aren’t reimbursed for medical home services that improve quality and
efficiency, such as care coordination, extended hours, and expanded modes of
communication (phone, email)
• PCPs aren’t supported in integrating behavioral health services into primary
care settings
• PCPs don’t always have the financial support to invest in practice
transformation
• How can we design a payment and delivery system that uses the potential of
primary care to improve access, patient experience, quality and efficiency?
3
Confidential draft / Policy under development / Statements are not binding on
MassHealth
Overview of Primary Care Payment Reform
• The goal of our strategy is improving access, patient experience, quality, and
efficiency through care management and coordination and integration of
behavioral health
• We believe that primary care is important in improving quality and efficiency
while preserving access, through a patient-centered medical home with integrated
behavioral health services
• The payment mechanism that supports that delivery model is a comprehensive
primary care payment (CPCP) combined with shared savings +/- risk arrangement
and quality incentives
• This program would span MassHealth managed care lives across the PCC Plan and
the Managed Care Organizations. We propose to launch a procurement for PCCs to
participate in the program and MCOs will participate in a similar payment
structure with these organizations
• We plan to implement on an aggressive timeframe, with an RFP release planned
in January 2013 and with 25% of members participating by July 2013, 50% of
members participating by July 2014, and 80% by July 2015
4
Confidential draft / Policy under development / Statements are not binding on
MassHealth
Proposed payment structure
The payment structure will not change billing for non-primary care services
(specialists, hospital); PCP’s will not be responsible for paying claims for
these services.
However, we are evaluating complementary alternative payment methodologies to
hospitals and specialists for acute services.
5
Comprehensive Primary Care Payment (CPCP)
• Risk-adjusted capitated payment for primary care services
• May include some behavioral health services
Quality Incentive Payment
• Annual incentive for quality performance, based on primary care performance
Shared savings payment
• Primary care providers share in savings on non primary care spend, including
hospital and specialist services
Confidential draft / Policy under development / Statements are not binding on
MassHealth
Proposed payment structure: Shared Savings
•Three tracks for shared savings / shared risk: Upside only
Upside only transitioning into downside risk Upside and downside risk from the
start
•All tracks will include quality gates and quality multipliers
(i.e., improved quality performance means higher shared savings payout)
• All tracks will include risk protection, such as truncation of claims for very
high-cost patients and risk corridors
6
Confidential draft / Policy under development / Statements are not binding on
MassHealth
MassHealth
Implementation path: Member protection
We look forward to working with stakeholders to ensure robust member protections
Key elements:
• Choice of PCC: Members remain free to switch primary care providers at any
time
• Patient experience impacts opportunity for quality incentive payments: Patient
experience survey data will serve as a key quality domain for quality incentive
and shared savings payments
• Notification requirements: Providers will be required to notify their patients
of their participation in the program and the potential impact on patients,
including any changes in practice operations that will affect patients
7
Confidential draft / Policy under development / Statements are not binding on
MassHealth
Agenda
• Recap of program
• Overview of open meeting / stakeholder engagement process
• Intersection with other programs
• Clarification of financial model
• Review of RFI feedback
8
Confidential draft / Policy under development / Statements are not binding on
MassHealth
Stakeholder engagement process
• RFI launched on August 6th, responses due September 7th; still reviewing
responses
• Six topic specific open meetings on a weekly basis:
• 10/10, 1:30-3pm, Transportation Building, Conference Room 5, Boston: Overview
• 10/17, 1-2:30pm, South Street Amphitheatre, Shrewsbury: Clinical Delivery
Model
• 10/22, 2:30-4pm, Worcester Public Library, Saxe Room, Worcester: Quality
metrics
• 10/31, 1:30-3pm, Transportation Building, Conference Room 5, Boston: Shared
savings
• 11/7, 1:30-3pm, Worcester Public Library, Saxe Room, Worcester: Comprehensive
Primary Care Payment
• 11/15, 1:30-3pm, 1 Ashburton Place, 21st floor, Boston: Provider eligibility
and technical assistance
• Provider town hall meetings
• More meetings for providers, members, and other stakeholders to be scheduled
• Public meetings to be posted on our website:
http://www.mass.gov/eohhs/gov/newsroom/masshealth/providers/primary-care-
payment-reform-initiative.html
9
Confidential draft / Policy under development / Statements are not binding on
MassHealth
Agenda
• Recap of program
• Overview of open meeting / stakeholder engagement process
• Intersection with other programs
• Clarification of financial model
• Review of RFI feedback
10
Confidential draft / Policy under development / Statements are not binding on
MassHealth
MassHealth has multiple programs to move towards integrated, accountable care
(^) For discussion today
Global Payment
FFS
True Accountable Care
Limited Integration
Full Care Integration
Degree of Integration
11
Payment Innovation
Asthma Pilot
“Business as Usual”
[Current L Market i
Duals
[PCPR J
IPCMHI
Health home -
DSTI
MBHP
Care
Mgmt
Delivery System Transformation
Confidential draft / Policy under development / Statements are not binding on
MassHealth
MassHealth
These initiatives are directed at different providers and different MassHealthh
populations
Populations
PCC Pla
MCO Plans
Duals
TPL / Other
Primary Care
Pedi Asthma
PCMHI Health
Behavioral Health
Homes
Hospitals / Specialists Care Mgmt
DSTI
PCPR
Long Term Support
Duals
Other
Confidential draft / Policy under development / Statements are not binding on
MassHealth
Across all our programs, we are attempting to align several elements
• Vision: We support medical home capabilities and primary care – behavioral
health integration across programs
• Quality metrics: We are aligning metrics as much as possible (and taking other
payers’ metrics into account)
• Reporting mechanisms: Across all programs, we are working to align ourselves
and our MCOs to ensure a smooth reporting process
13
Confidential draft / Policy under development / Statements are not binding on
MassHealth
MassHealth
At specific intersections, we have defined the effects on payment and delivery
system change
14
Intersection Plan
• PCPR and PCM
• PCMHI practices can transition into PCPR
• PCPR and Health Homes
• Health Homes benefits are for members with behavioral health conditions;
children will be served through the existing CBHI infrastructure, and adults
will select a “health home” that may or may not be the PCPR practice
• PCPR and MBHP Care Management
• MBHP care management services will support care management through the primary
care site
• PCPR and Pedi Asthma
• Practices will be allowed to participate in both
Confidential draft / Policy under development / Statements are not binding on
MassHealth
Agenda
• Recap of program
• Overview of open meeting / stakeholder engagement process
• Intersection with other programs
• Clarification of financial model
• Review of RFI feedback
15
Confidential draft / Policy under development / Statements are not binding on
MassHealth
Defining services in the comprehensive primary care payment
• Fee-for-service billable primary care services: We are analyzing best
practices for primary care to identify codes to include in the CPCP, including
primary care office visits, routine screenings, minor labs and office
procedures. We are also considering inclusion of other services such as
transportation and translation
• Non-fee-for-service billable medical home activities: We will not “open” new
fee for service codes, but will the build the CPCP amount to include the cost of
providing medical home services such as care coordination, care management, an
expanded care team, phone / email consultations, etc. Practices will have
flexibility in determining how to provide medical home services within the
constraints of the specified delivery model
• Fee-for-service billable behavioral health services: We plan to have three
“tiers” for including behavioral health services in the CPCP
• Tier 1: No fee-for-service billable services
• Tier 2: Fee-for-service billable outpatient behavioral health services
provided by master’s level and bachelor’s level professionals
• Tier 3: Fee-for-service outpatient behavioral health services provided by any
licensure level
• This topic will be covered in more detail at the November 7th meeting
dedicated to this topic and we look forward to continuing to hear your feedback
Confidential draft / Policy under development / Statements are not binding on
MassHealth
Risk adjusting the comprehensive primary care payment
• We are investing in risk adjustment tools by contracting with Verisk to
purchase and modify their Primary Care Activity Level risk adjustment; it uses
age, sex, and diagnostic conditions to predict the “primary care burden”
• We will work with stakeholders to evaluate options for risk adjusting on
social factors in year two and beyond
• We will endeavor to risk-adjust based on the most recent data available
• Changes in risk scores will account for increases in utilization driven by new
diagnoses; if enhanced primary care reveals addition needs of the population,
the risk adjustment process will enhance payments
• This topic will be covered in more detail at the November 7th meeting
dedicated to this topic and we look forward to continuing to hear your feedback
17
Confidential draft / Policy under development / Statements are not binding on
MassHealth
Designing the shared savings model
• Three tracks: Providers will select which track they would like to participate
in; providers in a risk-bearing track may be required to obtain DOI
certification as a risk-bearing provider organization. MassHealth is working
with DOI to align processes
• Minimum enrollee requirements: We are still setting minimum enrollee
thresholds, but PCCs will be able to apply together to meet those requirements
as a group. Participants with downside risk will have a minimum enrollee
requirement of 5,000; we may have a lower threshold for upside-only participants
• Services included will be all MassHealth covered benefits except services
included in the Comprehensive Primary Care Payment and potentially LTSS
services.
• Spending targets will be set based on historical spend with growth rates and
adjustments for changes in risk scores; we will risk adjust to account for
changes in risk scores over time
18
Confidential draft / Policy under development / Statements are not binding on
MassHealth
Agenda
• Recap of program
• Overview of open meeting / stakeholder engagement process
• Intersection with other programs
• Clarification of financial model
• Review of RFI feedback
19
Confidential draft / Policy under development / Statements are not binding on
MassHealth
RFI responses
• We have received over 30 responses to our RFI from a variety of stakeholders,
including providers, payers, and advocates
• RFI responses broadly expressed excitement about MassHealth’s desire to move
toward alternative payment and support primary care, and displayed a willingness
to continue to provide feedback
• We appreciate the thoughtfulness and depth of the RFI responses, and look
forward to continuing the dialogue with our stakeholder community
20
Confidential draft / Policy under development / Statements are not binding on
MassHealth
Review of RFI feedback (1/3)
RFI Comment MassHealth response
• The clinical delivery model as specified will impose significant additional
costs on practices in new staff, IT investments, etc.
• In designing the Comprehensive Primary Care Payment, MassHealth will review
the extent to which new responsibilities (e.g., care management) will incur new
costs for providers; this will be discussed further at subsequent meetings
• Additional sources of funding support these goals, including DSTI funding,
infrastructure and capacity building grants, Sec. 1202 increases in primary care
payments, HIT incentive payments
• Transforming practices will require significant time and technical assistance
given the significant departure from the fee for service delivery model
• MassHealth will work with MCO’s to provide technical assistance to
participants in receiving payments, taking on risk, forming relationships with
behavioral health providers, etc. in an aligned, team-based manner; this will be
discussed further at subsequent meetings
• We are considering building a one-year “technical assistance only” track to
support practices that would apply for the second round of the procurement
(which would go live in July 2014)
21
Confidential draft / Policy under development / Statements are not binding on
MassHealth
Review of RFI feedback (2/3)
RFI Comment MassHealth response
• Patients with severe and persistent mental illness need their “home” to be a
behavioral health site that receives payment for care management
• We are working with DPH to make it easier for behavioral health sites to bring
primary care in-house and become PCCs; the “technical assistance only” track
will include support for behavioral health sites trying to bring on PCPs
• Health Homes will provide an opportunity for a direct funding stream to
behavioral health sites, whether they have primary care on site or not
• Primary care practices will be required to outline their behavioral health
integration plan and their relationship with the behavioral health providers
that serve their patients; they may contract with BH providers to provide care
management / care coordination services
• Hospitals and specialists need to be part of the solution
• As the Health Policy Commission defines and certifies “Accountable Care
Organizations”, we will allow those entities to enroll in this program
• Provider organizations are encouraged to use existing ownership / affiliation
structures to align 22 incentives across providers
Confidential draft / Policy under development / Statements are not binding on
MassHealth
Review of RFI feedback (3/3)
RFI Comment MassHealth response
• Small practices will face unique difficulties in meeting this delivery model
• The “technical assistance only” track would help smaller practices think about
how they can work with each other, other providers and managed care
organizations to delivery care management, behavioral health integration, and
other services
• Pediatric practices have unique needs, including not all qualifying for HIT
incentive payments
• Pediatric practices may be excluded from HIT incentive payment requirements
• Real-time data notification is key for providers to be able to coordinate care
• MassHealth is working with hospitals to ensure enforcement with the 48-hr
notice requirement for ED visits / hospital discharges, and considering ways to
leverage the Health Information Exchange
• Aligning data provision across payers
• MassHealth is working with MCOs to create a uniform reporting mechanism for
claims-based reports, potentially leveraging the APCD
• Role of MCOs in care management
• MassHealth is working to ensure MCOs and MBHP can effectively support practice
based care management with data, staff, or other resources
23
Confidential draft / Policy under development / Statements are not binding on
MassHealth
Questions for discussion
• Are there any elements of the program as proposed that are unclear or
confusing?
• What are the benefits of this approach, given our goals of improving access,
patient experience, quality and efficiency?
• What are the drawbacks?
• Are there any major topics we haven’t mentioned yet?
• We look forward to continuing to receive your feedback. Please visit our
website at http://www.mass.gov/eohhs/gov/newsroom/masshealth/providers/primary-
care-payment-reform-initiative.html
• Our next open meeting will be 10/17, 1-2:30pm, South Street Amphitheatre,
Shrewsbury: Clinical Delivery Model
24